Public health authorities recommend symptom monitoring of healthcare personnel (HCP) after defined exposures to monkeypox. We report on the rapid development and implementation of mobile responsive survey solutions for notification of possible exposure, exposure risk assessment and stratification, and symptom monitoring.

An academic health center in Boston, Massachusetts, after admission of first diagnosed case of monkeypox in the United States during the current global outbreak.

Research Electronic Data Capture (REDCap) design and programmers, infection control, occupational health, and emergency preparedness specialists, and HCP with possible exposure to monkeypox.

Design and deployment of REDCap tools to identify HCP with possible exposure to monkeypox, to perform exposure risk assessment and stratification for postexposure prophylaxis (PEP), and to conduct symptom monitoring during the exposure window. Project enhancements included dashboards for HCP tracking and short message service (SMS text) reminders for symptom monitoring.

Tools to support the contact tracing and exposure investigation were deployed within 24 hours of identification of a patient with suspected monkeypox, with the full suite in production within 4 days of confirmation of the monkeypox diagnosis. Clinical follow-up of HCP was integrated into the design, and real-time versioning allowed for improvements in HCP symptom monitoring compliance and enhanced tracking.

During the current monkeypox outbreak, timely and comprehensive evaluation of potential HCP exposures is necessary but presents logistical challenges. Rapid development of monkeypox-specific solutions using REDCap facilitated flexibility in design and approach, and integration of targeted clinical support enhanced functionality.

To determine the utility of the Sofia SARS rapid antigen fluorescent immunoassay (FIA) to guide hospital-bed placement of patients being admitted through the emergency department (ED).

Cross-sectional analysis of a clinical quality improvement study.

This study was conducted in 2 community hospitals in Maryland from September 21, 2020, to December 3, 2020. In total, 2,887 patients simultaneously received the Sofia SARS rapid antigen FIA and SARS-CoV-2 RT-PCR assays on admission through the ED.

Rapid antigen results and symptom assessment guided initial patient placement while confirmatory RT-PCR was pending. The sensitivity, specificity, positive predictive values, and negative predictive values of the rapid antigen assay were calculated relative to RT-PCR, overall and separately for symptomatic and asymptomatic patients. Assay sensitivity was compared to RT-PCR cycle threshold (Ct) values. Assay turnaround times were compared. Clinical characteristics of RT-PCR–positive patients and potential exposures from false-negative antigen assays were evaluated.

For all patients, overall agreement was 97.9%; sensitivity was 76.6% (95% confidence interval [CI], 71%–82%), and specificity was 99.7% (95% CI, 99%–100%). We detected no differences in performance between asymptomatic and symptomatic individuals. As RT-PCR Ct increased, the sensitivity of the antigen assay decreased. The mean turnaround time for the antigen assay was 1.2 hours (95% CI, 1.0–1.3) and for RT-PCR it was 20.1 hours (95% CI, 18.9–40.3) (P < .001). No transmission from antigen-negative/RT-PCR–positive patients was identified.

Although not a replacement for RT-PCR for detection of all SARS-CoV-2 infections, the Sofia SARS antigen FIA has clinical utility for potential initial timely patient placement.

Patients admitted to the hospital may unknowingly carry severe acute respiratory coronavirus virus 2 (SARS-CoV-2), and hospitals have implemented SARS-CoV-2 admission screening. However, because SARS-CoV-2 reverse-transcription polymerase chain reaction (RT-PCR) assays may remain positive for months after infection, positive results may represent active or past infection. We determined the prevalence and infectiousness of patients who were admitted for reasons unrelated to COVID-19 but tested positive for SARS-CoV-2 on admission screening.

We conducted an observational study at the University of Iowa Hospitals & Clinics from July 7 to October 25, 2020. All patients admitted without suspicion of COVID-19 were included, and medical records of those with a positive admission screening test were reviewed. Infectiousness was determined using patient history, PCR cycle threshold (Ct) value, and serology.

In total, 5,913 patients were screened and admitted for reasons unrelated to COVID-19. Of these, 101 had positive admission RT-PCR results; 36 of these patients were excluded because they had respiratory signs/symptoms on admission on chart review. Also, 65 patients (1.1%) did not have respiratory symptoms. Finally, 55 patients had Ct values available and were included in this analysis. The median age of the final cohort was 56 years and 51% were male. Our assessment revealed that 23 patients (42%) were likely infectious. The median duration of in-hospital isolation was 5 days for those likely infectious and 2 days for those deemed noninfectious.

SARS-CoV-2 was infrequent among patients admitted for reasons unrelated to COVID-19. An assessment of the likelihood of infectiousness using clinical history, RT-PCR Ct values, and serology may help in making the determination to discontinue isolation and conserve resources.

Patients presenting to hospital with suspected coronavirus disease 2019 (COVID-19), based on clinical symptoms, are routinely placed in a cohort together until polymerase chain reaction (PCR) test results are available. This procedure leads to delays in transfers to definitive areas and high nosocomial transmission rates. FebriDx is a finger-prick point-of-care test (PoCT) that detects an antiviral host response and has a high negative predictive value for COVID-19. We sought to determine the clinical impact of using FebriDx for COVID-19 triage in the emergency department (ED).

We undertook a retrospective observational study evaluating the real-world clinical impact of FebriDx as part of an ED COVID-19 triage algorithm.

Emergency department of a university teaching hospital.

Patients presenting with symptoms suggestive of COVID-19, placed in a cohort in a ‘high-risk’ area, were tested using FebriDx. Patients without a detectable antiviral host response were then moved to a lower-risk area.

Between September 22, 2020, and January 7, 2021, 1,321 patients were tested using FebriDx, and 1,104 (84%) did not have a detectable antiviral host response. Among 1,104 patients, 865 (78%) were moved to a lower-risk area within the ED. The median times spent in a high-risk area were 52 minutes (interquartile range [IQR], 34–92) for FebriDx-negative patients and 203 minutes (IQR, 142–255) for FebriDx-positive patients (difference of −134 minutes; 95% CI, −144 to −122; P < .0001). The negative predictive value of FebriDx for the identification of COVID-19 was 96% (661 of 690; 95% CI, 94%–97%).

FebriDx improved the triage of patients with suspected COVID-19 and reduced the time that severe acute respiratory coronavirus virus 2 (SARS-CoV-2) PCR-negative patients spent in a high-risk area alongside SARS-CoV-2–positive patients.

To study the airflow, transmission, and clearance of aerosols in the clinical spaces of a hospital ward that had been used to care for patients with coronavirus disease 2019 (COVID-19) and to examine the impact of portable air cleaners on aerosol clearance.

Observational study.

A single ward of a tertiary-care public hospital in Melbourne, Australia.

Glycerin-based aerosol was used as a surrogate for respiratory aerosols. The transmission of aerosols from a single patient room into corridors and a nurses’ station in the ward was measured. The rate of clearance of aerosols was measured over time from the patient room, nurses’ station and ward corridors with and without air cleaners [ie, portable high-efficiency particulate air (HEPA) filters].

Aerosols rapidly travelled from the patient room into other parts of the ward. Air cleaners were effective in increasing the clearance of aerosols from the air in clinical spaces and reducing their spread to other areas. With 2 small domestic air cleaners in a single patient room of a hospital ward, 99% of aerosols could be cleared within 5.5 minutes.

Air cleaners may be useful in clinical spaces to help reduce the risk of acquisition of respiratory viruses that are transmitted via aerosols. They are easy to deploy and are likely to be cost-effective in a variety of healthcare settings.

Discomfort and device-related pressure injury (DRPI) caused by N95 filtering facepiece respirators (FFRs) are common. The use of prophylactic hydrocolloid dressings is one of the strategies that may improve comfort and reduce DRPI. In this study, we investigated the impact of these dressings on N95 respirator fit.

We performed a repeat quantitative fit testing through the Respiratory Protection Program on 134 healthcare workers (HCWs), who applied hydrocolloid dressings on the bridge of their nose under the N95 FFRs that they passed the initial fit test with, but reported discomfort with the FFR.

With the hydrocolloid dressings in place, the fit-test pass rate for the semirigid cup style (3M 1860) was 94% (108 of 115); for the the vertical flat-fold style (BYD), the pass rate was 85% (44 of 52); for the duckbill style (BSN medical ProShield and Halyard Fluidshield), the pass rate was 81% (87 of 108); and for the 3-panel flat-fold style (3M Aura) N95 FFRs, the pass rate was 100% (3 of 3). There was a statistically significant reduction in the overall fit factors for both the vertical flat-fold and duckbill type N95 respirators after the application of hydrocolloid dressings.

Hydrocolloid dressings are likely to disturb the mask seal for nonrigid-style N95 FFRs, particularly the vertical flat-fold style and the duckbill style N95 FFRs. Given the risk of mask seal disturbance of N95 respirators as shown in this study, we advocate that any HCW requiring the use of prophylactic dressings should undergo repeat quantitative fit testing with the dressing in place prior to using the dressing and mask in combination.

To evaluate trends in racial and ethnic disparities in weekly cumulative rates of coronavirus disease 2019 (COVID-19) cases and deaths in Connecticut nursing homes.

Longitudinal analysis of nursing-home COVID-19 reports and other databases. Multivariable negative binomial models were used to estimate disparities in COVID-19 incidence and fatality rates across nursing-home groups with varying proportions of racial and ethnic minority residents, defined as low-, medium-, medium-high-, and high-proportion groups. Trends in such disparities were estimated from week 1 (April 13) to week 10 (ending on June 19, 2020).

The study was conducted across 211 nursing homes.

The average number of cases ranged from 6.1 cases per facility for the low-proportion group to 11.7 cases per facility for the high-proportion group in week 1, and from 26.7 to 58.5 cases per facility in week 10. Compared to the low-proportion group, the adjusted incidence rate ratios (IRRs) for the high-proportion group were 1.18 (95% confidence interval [CI], 0.77–1.80; P > .10) in week 1 and 1.54 (95% CI, 1.05–2.25; P < .05) in week 10, showing a 30% (95% CI, 5%–62%) relative increase (P < .05). The average weekly number of COVID-19–related deaths ranged from 0 to 0.3 deaths per facility for different groups in week 1, and from 7.6 to 13.3 deaths per facility in week 10. Adjusted disparities in fatalities similarly increased over time.

Connecticut nursing homes caring for predominately racial and ethnic minority residents tended to have higher COVID-19 incidence and fatality rates. These across-facility disparities increased during the early periods of the pandemic.

Residents of long-term care facilities face significantly greater risk of contracting or dying from coronavirus disease 2019 (COVID-19). However, little is known about COVID-19 in assisted living communities (ALCs) and the potential determinants of its spread. We examined the association between COVID-19 cases in ALCs and the proportion of Medicare-Medicaid (dual) eligible minority residents, neighborhood area deprivation, and state COVID-19 policy stringency.

We conducted longitudinal analyses employing data on confirmed COVID-19 cases in ALCs in 5 states. We sought to determine the weekly cumulative number of COVID-19 cases in ALCs. Covariates were ALC characteristics, area deprivation index, and state COVID-19 policy stringency. Multivariate 2-part models were used to determine the associations between independent variables and the likelihood of an outbreak and the overall count of cases.

In our study sample, 201 ALCs (7.04%) reported 1 or more COVID-19 cases as of August 17, 2020. A higher percentage of minority residents was associated with an increased likelihood of an ALC reporting at least 1 COVID-19 case (odds ratio [OR], 1.06; P = .032). Conditional on having at least 1 case, ALCs in states with stricter social distancing policies had lower case counts (incidence rate ratio [IRR], 0.98; P < .001). Greater neighborhood deprivation was associated with higher case count (IRR, 1.36; P = .049).

ALCs with higher proportions of dual-eligible minority residents were more likely to have COVID-19 outbreaks within their communities. ALCs located in more socioeconomically deprived neighborhoods, and in states with less stringent state social distancing policies, tended to have more COVID-19 cases.

Ventilator-capable skilled nursing facilities (vSNFs) are critical to the epidemiology and control of antibiotic-resistant organisms. During an infection prevention intervention to control carbapenem-resistant Enterobacterales (CRE), we conducted a qualitative study to characterize vSNF healthcare personnel beliefs and experiences regarding infection control measures.

A qualitative study involving semistructured interviews.

One vSNF in the Chicago, Illinois, metropolitan region.

The study included 17 healthcare personnel representing management, nursing, and nursing assistants.

We used face-to-face, semistructured interviews to measure healthcare personnel experiences with infection control measures at the midpoint of a 2-year quality improvement project.

Healthcare personnel characterized their facility as a home-like environment, yet they recognized that it is a setting where germs were ‘invisible’ and potentially ‘threatening.’ Healthcare personnel described elaborate self-protection measures to avoid acquisition or transfer of germs to their own household. Healthcare personnel were motivated to implement infection control measures to protect residents, but many identified structural barriers such as understaffing and time constraints, and some reported persistent preference for soap and water.

Healthcare personnel in vSNFs, from management to frontline staff, understood germ theory and the significance of multidrug-resistant organism transmission. However, their ability to implement infection control measures was hampered by resource limitations and mixed beliefs regarding the effectiveness of infection control measures. Self-protection from acquiring multidrug-resistant organisms was a strong motivator for healthcare personnel both outside and inside the workplace, and it could explain variation in adherence to infection control measures such as a higher hand hygiene adherence after resident care than before resident care.

To investigate the frequency of environmental contamination in hospital areas outside patient rooms and in outpatient healthcare facilities.

Culture survey.

This study was conducted across 4 hospitals, 4 outpatient clinics, and 1 surgery center.

We conducted 3 point-prevalence culture surveys for methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, Clostridioides difficile, Candida spp, and gram-negative bacilli including Enterobacteriaceae, Pseudomonas aeruginosa, Acinetobacter baumanii, and Stenotrophomonas maltophilia in each facility. In hospitals, high-touch surfaces were sampled from radiology, physical therapy, and mobile equipment and in emergency departments, waiting rooms, clinics, and endoscopy facilities. In outpatient facilities, surfaces were sampled in exam rooms including patient and provider areas, patient bathrooms, and waiting rooms and from portable equipment. Fluorescent markers were placed on high-touch surfaces and removal was assessed 1 day later.

In the hospitals, 110 (9.4%) of 1,195 sites were positive for 1 or more bacterial pathogens (range, 5.3%–13.7% for the 4 hospitals) and 70 (5.9%) were positive for Candida spp (range, 3.7%–5.9%). In outpatient facilities, 31 of 485 (6.4%) sites were positive for 1 or more bacterial pathogens (range, 2% to 14.4% for the 5 outpatient facilities) and 50 (10.3%) were positive for Candida spp (range, 3.9%–23.3%). Fluorescent markers had been removed from 33% of sites in hospitals (range, 28.4%–39.7%) and 46.3% of sites in outpatient clinics (range, 7.4%–82.8%).

Surfaces in hospitals outside patient rooms and in outpatient facilities are frequently contaminated with healthcare-associated pathogens. Improvements in cleaning and disinfection practices are needed to reduce contamination.

In 2017, a point-prevalence survey was conducted with 12,931 patients in 96 hospitals across Switzerland as part of the national strategy to prevent healthcare-associated infections (HAIs). We present novel statistical methods to assess incidence proportions of HAI and attributable length-of-stay (LOS) in point-prevalence surveys.

Follow-up data were collected for a subsample of patients and were used to impute follow-up data for all remaining patients. We used weights to correct length bias in logistic regression and multistate analyses. Methods were also tested in simulation studies.

The estimated incidence proportion of HAIs during hospital stay and not present at admission was 2.3% (95% confidence intervals [CI], 2.1–2.6), the most common type being lower respiratory tract infections (0.8%; 95% CI, 0.6–1.0). Incidence proportion was highest in patients with a rapidly fatal McCabe score (7.8%; 95% CI, 5.7–10.4). The attributable LOS for all HAI was 6.4 days (95% CI, 5.6–7.3) and highest for surgical site infections (7.1 days, 95% CI, 5.2–9.0). It was longest in the age group of 18–44 years (9.0 days; 95% CI, 5.4–12.6). Risk-factor analysis revealed that McCabe score had no effect on the discharge hazard after infection (hazard ratio [HR], 1.21; 95% CI, 0.89–1.63). Instead, it only influenced the infection hazard (HR, 1.84; 95% CI, 1.39–2.43) and the discharge hazard prior to infection (HR, 0.73; 95% CI, 0.66–0.82).

In point-prevalence surveys with limited follow-up data, imputation and weighting can be used to estimate incidence proportions and attributable LOS that would otherwise require complete follow-up data.

Urine cultures have poor specificity for catheter-associated urinary tract infections (CAUTIs). We evaluated the effect of a urine-culture stewardship program on urine culture utilization and CAUTI in adult intensive care units (ICUs).

A quasi-interventional study was performed from 2015 to 2017.

The study cohort comprised 21,367 patients admitted to the ICU at a teaching hospital.

The urine culture stewardship program included monthly 1-hour discussions with ICU house staff emphasizing avoidance of “pan-culture” for sepsis workup and obtaining urine culture only if a urinary source of sepsis is suspected. The urine culture utilization rate metric (UCUR; ie, no. urine cultueres/catheter days ×100) was utilized to measure the effect. Monthly UCUR, catheter utilization ratio (CUR), and CAUTI rate were reported on an interactive quality dashboard. To ensure safety, catheterized ICU patients (2015–2016) were evaluated for 30-day readmission for UTI. Time-series data and relationships were analyzed using Spearman correlation coefficients and regression analysis.

Urine culture utilization decreased from 3,081 in 2015 to 2,158 in 2016 to 1,218 in 2017. CAUTIs decreased from 78 in 2015 to 60 in 2016 and 28 in 2017. Regression analysis over time showed significant decreases in UCUR (r, 0.917; P < .0001) and CAUTI rate (r, 0.657; P < .0001). The co-correlation between UCUR and CAUTI rate was (r, 0.625; P < .0001) compared to CUR and CAUTI rate (r, 0.523; P = .004). None of these patients was readmitted with a CAUTI.

Urine culture stewardship program was effective and safe in reducing UC overutilization and was correlated with a decrease in CAUTIs. Addition of urine-culture stewardship to standard best practices could reduce CAUTI in ICUs.

Inpatient surgical site infections (SSIs) cause morbidity in children. The SSI rate among pediatric ambulatory surgery patients is less clear. To fill this gap, we conducted a multiple-institution, retrospective epidemiologic study to identify incidence, risk factors, and outcomes.

We identified patients aged <22 years with ambulatory visits between October 2010 and September 2015 via electronic queries at 3 medical centers. We performed sample chart reviews to confirm ambulatory surgery and adjudicate SSIs. Weighted Poisson incidence rates were calculated. Separately, we used case–control methodology using multivariate backward logistical regression to assess risk-factor association with SSI.

In total, 65,056 patients were identified by queries, and we performed complete chart reviews for 13,795 patients; we identified 45 SSIs following ambulatory surgery. The weighted SSI incidence following pediatric ambulatory surgery was 2.00 SSI per 1,000 ambulatory surgeries (95% confidence interval [CI], 1.37–3.00). Integumentary surgeries had the highest weighted SSI incidence, 3.24 per 1,000 ambulatory surgeries (95% CI, 0.32–12). The following variables carried significantly increased odds of infection: clean contaminated or contaminated wound class compared to clean (odds ratio [OR], 9.8; 95% CI, 2.0–48), other insurance type compared to private (OR, 4.0; 95% CI, 1.6–9.8), and surgery on weekend day compared to weekday (OR, 30; 95% CI, 2.9–315). Of the 45 instances of SSI following pediatric ambulatory surgery, 40% of patients were admitted to the hospital and 36% required a new operative procedure or bedside incision and drainage.

Our findings suggest that morbidity is associated with SSI following ambulatory surgery in children, and we also identified possible targets for intervention.

Limited data are available on the implementation of an area under the concentration-time curve (AUC)–based dosing protocol with multidisciplinary team (MT) support to improve adherence with vancomycin dosing protocol.

To evaluate the effectiveness of an AUC-based dosing protocol with MT support intervention with adherence to a hospital-wide vancomycin dosing protocol at Thammasat University Hospital.

We conducted a quasi-experimental study in patients who were prescribed intravenous vancomycin. The study was divided into 2 periods; (1) the preintervention period when the vancomycin dosing protocol was already applied in routine practice and (2) the post-intervention period when the implementation of an AUC-based dosing protocol with MT support was added to the existing vancomycin dosing protocol. The primary outcome was the rate of adherence, and the secondary outcomes included acute kidney injury events, vancomycin-related adverse events, and 30-day mortality rate.

In total, 240 patients were enrolled. The most common infections were skin and soft-tissue infections (24.6%) and bacteremia (24.6%). The most common pathogens were coagulase-negative staphylococci (19.6%) and Enterococcus spp (15.4%). Adherence with the vancomycin dosing protocol was significantly higher in the postintervention period (90.8% vs 55%; P ≤ .001). By multivariate analysis, an AUC-based dosing protocol with MT support was the sole predictor for adherence with the vancomycin dosing protocol (adjusted odds ratio, 10.31; 95% confidence interval, 4.54–23.45; P ≤ .001). The 30-day mortality rate was significantly lower during the postintervention period (8.3% vs 20%; P = .015).

AUC-based dosing protocol with MT support significantly improved adherence with vancomycin dosing protocol and was associated with a lower 30-day mortality rate.